Provider Demographics
NPI:1861922601
Name:MERRELL, JASON PORTER (OD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:PORTER
Last Name:MERRELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 E LUNA BLANCA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-8466
Mailing Address - Country:US
Mailing Address - Phone:208-390-0826
Mailing Address - Fax:
Practice Address - Street 1:1606 S SIGNAL BUTTE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-1482
Practice Address - Country:US
Practice Address - Phone:480-358-9737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002328152W00000X
IDODP-100409152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist